Anecdotal Records
Anecdotal Records
Anecdotal Records
SUBMITTED TO –
Prof. Sabitri Kuila
Vice Principal SUBMITTED BY –
Apollo College of Nursing, Kolkata
Shubhrima Khan
M.Sc. Nursing 2nd year
Apollo College of Nursing, Kolkata
ANECDOTAL RECORDS
An anecdotal record is an observation that is written like a short story. They are descriptions
of incidents or events that are important to the person observing. Anecdotal records are short,
objective and as accurate as possible.
Definition
According to Randall, Anecdotal records are a record of some significant item of conduct, a
record of an episode in the life of students, a word picture of the student in action, a word
snapshot at the moment of the incident, any narration of events in which may be significant
about his personality.
Advantages
Used for formative feedback
Economical and easy to develop
Provision of insight
It helps in clinical service practices
It provides description of actual behaviour in a natural situation
This technique is especially useful for evaluating nursing students in clinical setting
It can be used for supplementation and validation of other more structured instruments
It can be used to record observations related to clinical competencies and for
evaluation of student’s performance
They provide specific and exact description of personality, ability, or skill and
minimize generalization
Disadvantages
They tend to be less reliable than another observational tool as they tend to be less
formal and systematic
They are time consuming to write
The observers tend to record only undesirable incident and neglect the positive
incident
The nursing teacher may not have the skill to write anecdotes correctly and use them
properly
It is lack standardization, has difficulties in scoring and have limited application
SAMPLE ANECDOTAL RECORD
Comments / Notes:
Bhoomika, being belonging to the special child category, was presumed to show certain
unexplained behaviour. She has been part of group activities and has rarely indulged in
isolation activities. She initially might have not listened to us, later realising her behaviour she
called back the students to learn with her, which is her normal behaviour.
Generally, according to health care guidelines, the report must be filled out as soon as
possible following the incident (but after the situation h weas been stabilized). This way, the
details written in the report are as accurate as possible.
Most incident reports that are written involve accidents with patients, such as patient falls.
But most facilities will also document an incident in which a staff member or visitor is
injured.
Definition
To ensure the details are as accurate as possible, incident reports should be completed within
24 hours by whomever witnessed the incident. If the incident wasn’t observed (e.g., a patient
slipped, fell, and got up on his own), then the first person who was notified should submit it.
For the most part, these incident reports are completed by nurses or other licensed personnel
and are used for risk management, quality assurance, educational, and legal purposes.
In the event that an incident involves a patient, the patient will often be monitored for a
period of time following the incident (for it may happen again), which may include
taking vital signs regularly.
Incident reports comprise two aspects. First, there is the actual reporting of any particular
incident (this may be something affecting you, your patient or other staff members), and the
relevant corrective action taken. Secondly, information from incident reports is analysed to
identify overall improvements in the workplace or service.
Purpose of an Incident Report
1. Risk management: Incident report data is used to identify and eliminate potential risks
necessary to prevent future mistakes. For example, if an incident report review finds that
most medical errors occur during shift changes, risk management teams may suggest that
nursing staff develop standardized turnover protocols to avoid future errors.
3. Educational tools: Incident reports make great training tools because everyone has an
innate ability to learn from their mistakes or the mistakes of others. Healthcare teams
often use resolved incident reports as educational tools to prevent similar occurrences.
The name of the person(s) affected and the names of any witnesses to an incident
Where and when the incident occurred
The events surrounding the incident
Whether an injury occurred as a direct result of the incident
The response and corrective measures that were taken
It should be signed and dated prior to handing it in to the appropriate person, such as a
supervisor
Examples include:
Injuries – physical such as falls and needle sticks, or mental such as verbal abuse
Errors in patient care and medication errors
Patient complaints, any episodes of aggression
Faulty equipment or product failure (such as running out of oxygen)
Any incident in which patient or staff safety is compromised
Important points:
Prevention of incidents
Assess clients for allergies and intervene as needed (e.g., food, latex, environmental
allergies)
Determine client/staff member knowledge of safety procedures
Identify factors that influence accident/injury prevention (e.g., age, developmental
stage, lifestyle, mental status)
Identify deficits that may impede client safety (e.g., visual, hearing,
sensory/perceptual)
Identify and verify prescriptions for treatments that may contribute to an accident or
injury (does not include medication)
Identify and facilitate correct use of infant and child car seats
Provide the client with appropriate method to signal staff members
Protect the client from injury (e.g., falls, electrical hazards)
Review necessary modifications with client to reduce stress on specific muscle or
skeletal groups (e.g., frequent changing of position, routine stretching of the
shoulders, neck, arms, hands, fingers)
Implement seizure precautions for at-risk clients
Make appropriate room assignments for cognitively impaired clients
Ensure proper identification of client when providing care
Verify appropriateness and/or accuracy of a treatment order
General information
Registration number…………………………………
Address………………………………………………………………………………………….
Phone…………………………… Email……………………………………..……..
Report prepared by
Name………………………………………... Designation……………………………..
Nature of incident…………………………………………………………………………….....
Witnesses……………………………… Affected
people………………………….
Damage is
caused………………………………………………………………………………..
Total cost of
damage…………………………………………………………………………….
Signature: _________________
A day or night report is a written report where the information is used by several health
professionals to carry out health related activities of a client. It is a clinical, scientific, and
administrative and legal document related to nursing care given to the individual, family and
community.
Purposes
Supply data that are essential for programme planning and evaluation.
Provide the practitioner with data required for the application of professional services
for the improvement of family's health.
Tools of communication between health workers, the family & other development
personnel Effective health records show the health problem in the family and other
factors that affect health.
Indicates plans for future.
Help in the research for improvement of nursing care.
Principles
Nurses should develop their own method of expression and form in record writing.
Written clearly, appropriately and adequately.
Contain facts based on observation, conversation and action.
Select relevant facts and the recording should be neat, complete and uniform
Valuable legal documents and so it should be handled carefully, and accounted for.
Records should be written immediately after an interview.
Records are confidential documents.
Accurately dated, timed and signed
Not include abbreviations, jargon, meaningless phrases
Importance
Reports should be made promptly if they are to serve their purpose well.
A good report is clear, complete, concise.
If it is written all pertinent, identifying data are include – the date and time, the people
concerned, the situation, the signature of the person making the report.
It is clearly stated and well organized for easy understanding.
No extraneous material is included.
Good oral reports are clearly expressed and presented in an interesting manner.
Important points are emphasized.
Nurse’s responsibility:
patient has a right to inspect and copy the record after being discharged
Failure to record significant patient information on the medical record makes a nurse
guilty of negligence.
Medical record must be accurate to provide a sound basis for care planning.
Errors in nursing charting must be corrected promptly in a manner that leaves no doubts
about the facts.
In reporting information about criminal acts obtained during patient care, the nurse must
reveal such information only to the police, because it is considered a privileged
communication.
FACT: Information about clients and their care must be functional. A record should
contain descriptive, objective information about what a nurse sees, hears, feels and
smells.
ACCURACY: A client record must be reliable. Information must be accurate so that
health team members have confidence in it.
COMPLETENESS: The information within a recorded entry or a report should be
complete, containing concise and thorough information about a client care or any event or
happening taking place in the jurisdiction of manger.
CURRENTNESS: Delays in recording or reporting can result in serious omissions and
untimely delays for medical care or action legally, a late entry in a chart may be
interpreted on negligence.
ORGANIZATION: The nurse or nurse manager communicates information in a logical
format or order. Health team members understand information better when it is given in
the order in which it is occurred.
CONFIDENTIALITY: Nurses are legally and ethically obligated to keen information
about client’s illnesses and treatments confidential.
2.
3.
4.
5.
………………………………. ………………………………………….
Signature of the Duty Nurse Signature of the Nursing Superintendent
Date: Date:
CURRICULUM VITAE
A nursing CV is the equivalent of a nursing resume. It’s application document that outlines
your skills, work experience, and education to allow employers to see that one has the
required credentials and licenses to perform the duties of a nurse.
Standard CV format guides hiring managers through your CV effectively. It starts with a
summary statement to hook their attention, and then leads them quickly through your skills
section into your experience information, which describes your previous jobs in great detail.
Your CV should then close with a brief education section.
Contact Information
Name
Address
Telephone
Cell Phone
Email
Education: Include dates, majors, and details of degrees, training, and certification
University
Graduate School
Doctoral Education
Post-Doctoral Training
Employment History List in chronological order, most recent first and include position dates
Work History
Research (if any)
Professional Qualifications
Certifications and Accreditations
Computer Skills
List courses taught/ developed and places
Awards, Presentations (Indicate if peer reviewed, and whether a poster or podium
presentation), Publications, Books, Professional Memberships, Committee
Participation, Interests
Although every nursing role will be different, there are certain skills that are essential to
nurses across the board.
1. Patient care – The ability to care for patients is paramount to a nurse’s skill set and
should be evident throughout the CV.
2. Knowledge of medication – Administering medications and understanding their effects is
another crucial skill for most nurses.
3. Ward management – Not only is this skill useful if you plan on climbing the ranks within
a ward, but it will also show that you know how a ward is run, and have a deeper insight
into staffing levels and patient bed allocation charts.
4. Hygiene and health – Ensuring you know what your patient’s area eating, and that they
are clean and comfortable in their beds
DOs:
Maintain plenty of white space (in the margins, between listings, etc.)
Using large enough type font to make it easy to read
Preserve order by labelling each page with your name and the page number
Organize content by providing clear explanations and intuitive listings/sections
Proofread information to catch errors
If longer than one page, include name and page number on each page after the first
DON’Ts:
Don’t have any typos due to spelling or grammatical errors
Don’t rely on your computer program’s spell check function; it won’t detect when you’ve
substituted the wrong word (e.g. effect vs. affect)
Don’t ignore aesthetics: Don’t skimp on space by cramming your content together,
minimizing margins or lumping separate ideas into lengthy paragraphs; emphasize
independent points with separations so that your CV will be easy to read
Don’t include private personal information such as age, ethnicity, political affiliation,
religion, social security number, marital status, place of birth, height, sexual orientation,
weight or health information
Name:
ADDRESS:
Phone:
E-mail:
OBJECTIVE
To seek challenging assignments and responsibilities with a platform to achieve
organizational objectives and an opportunity for growth and career advancement with full
utilization of my profound professional and practical experience.
ACADEMIC QUALIFICATION
Name of Name of Medium
Year Name of board Percentage Remarks
examination institution of study
Secondary
examination
Higher
secondary
examination
PROFESSIONAL QUALIFICATION
Course Name of Name of Name of
Year Percentage Remarks
examination institution University
B.Sc. B.Sc.
Nursing Nursing Part
IV
B.Sc.
Nursing Part
III
B.Sc.
Nursing Part
II
B.Sc.
Nursing Part
I
M.Sc. M.Sc.
Nursing Nursing Part
I
Specialty –
Mental M.Sc.
Health Nursing Part
Nursing II
WORK EXPERIENCE
Name of the institution | designation
Address:
Experience: [date] – [date]
DECLARATION
I vouch all the information declared above is true to the best of my knowledge and what
stated are correct and complete. I will try my best to execute the responsibility entrusted upon
me.
Date:
Place:
Signature
OFFICIAL LETTER
An official letter is one written in a formal and ceremonious language and follows a certain
stipulated format. Such letters are written for official purposes to authorities, dignitaries,
colleagues, seniors, etc and not to personal contacts.
Importance
It is very important to know how to write an official letter format, since it is based on this
format that major aspects are addressed.
There are many situations that arise in which an individual may need to address a variety
of issues with an institution or when applying for their first job.
A well written letter holds more weight than one would imagine; it definitely weighs on
your ability to land the job you want. The importance of an official letter cannot be
understated. In order for your letter to be appreciated and noticed, it has to be
exceptionally well written.
Mastering the art of writing a good letter for official purposes will prove to be extremely
beneficial in the long run.
Purposes
1. Sender’s Address: The sender’s address is usually put on the top right-hand corner of the
page. The address should be complete and accurate in case the recipient of the letter
wishes to get in touch with the sender for further communication.
2. Date: The sender’s address is followed by the date just below it, i.e. on the right side of
the page. This is the date on which the letter is being written. It is important in formal
letters as they are often kept on record.
3. Receiver’s Address: After leaving some space we print the receiver’s address on the left
side of the page. Whether to write “To” above the address depends on the
writer’s preference. Make sure you write the official title/name/position etc of the
receiver, as the first line of the address.
4. Greeting: This is where you greet the person you are addressing the letter to. Bear in
mind that it is a formal letter, so the greeting must be respectful and not too personal. The
general greetings used in formal letters are “Sir” or “Madam”. If you know the name of
the person the salutation may also be “Mr. XYZ” or “Ms. ABC”. But remember you
cannot address them only by their first name. It must be the full name or only their last
name.
5. Subject: After the salutation/greeting comes the subject of the letter. In the centre of the
line write ‘Subject” followed by a colon. Then we sum up the purpose of writing the letter
in one line. This helps the receiver focus on the subject of the letter in one glance.
6. Body of the Letter: This is the main content of the letter. It is either divided into three
paras or two paras if the letter is briefer. The purpose of the letter should be made clear in
the first paragraph itself. The tone of the content should be formal. Do not use any
flowery language. Another point to keep in mind is that the letter should be concise and to
the point. And always be respectful and considerate in your language, no matter the
subject of your letter.
7. Closing the Letter: At the end of your letter, we write a complimentary losing. The words
“Yours Faithfully” or “Yours Sincerely” are printed on the right side of the paper.
Generally, we use the later if the writer knows the name of the person.
8. Signature: Here finally you sign your name. And then write your name in block letters
beneath the signature. This is how the recipient will know who is sending the letter.
SAMPLE OF AN OFFICIAL LETTER
Date:
To
The principal,
Apollo Gleneagles Nursing College
RGN/A/S/1044, Gopalpur
Narayanpur, Battala
Kolkata – 136
Subject: Requesting Permission for conducting dissertation work for the fulfilment of
M.Sc. Nursing Programme.
Respected Madam,
With due respect and humble submission, I would like to inform you that, myself Ms.
Shubhrima Khan, M. Sc. Nursing Student of your institution, would like inform you that for
the course requirement as per regulation of The West Bengal University of Health Sciences I
have to conduct a research study.
Title of the research study “A study to assess the prevalence, associated factors and health
seeking behaviour regarding psychiatric morbidity among caregivers of mentally ill patient
attending psychiatric Out Patient Department in Kolkata, West Bengal” under the guidance of
Madam Kalyani Saha, Professor, Apollo Gleneagles Nursing College and Ms. Aruna Kumari,
Associate Professor, Apollo College of Nursing
I will be highly obliged if you kindly give the permission to conduct the proposed study.
Thanking you,
Your sincerely
Shubhrima Khan
M.Sc. Nursing part II